Question Authority: The Need for Anti-Authoritarians in the Medical Profession

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Anti-authoritarians question whether an authority is a legitimate one before taking that authority seriously.  images-24To evaluate the legitimacy of  an authority it is necessary to:
1. Assess whether they actually know what they are talking about.   2. Assess whether the authorities are honest in their intentions.
When anti-authoritarians assess an authority to be illegitimate, they challenge and resist that authority.
There is a paucity of anti-authoritarianism in the medical community concerning groups that have gained tremendous sway in the regulation of the medical profession.    There is, in fact, an absence of anti-authoritarian questioning  of  what is essentially illegitimate and irrational authority.
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Most doctors are unaware of the impact these organizations have had on both the regulation of the medical profession and social control of individual doctors.  Through “moral entrepreneurship” and “bent science” these groups have successfully swayed both policy-makers and the public to support an agenda not supported by reality testing or critical thinking.  This acceptance without investigation has led to a deterioration of professional ethics and evidence-based decision making in the regulation of the medical profession.
 In order for these organizations to maintain power it is necessary that their authoritative opinion remain unquestioned and unchallenged.  Consciously manufactured propaganda has persuaded regulatory and public opinion of their value and to maintain power it is necessary that this authority remain insulated from outside evaluation because the entire system is based on assumptions that can be aptly characterized as “illusions.
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The dogmatic statements and abusive generalizations do not conform to reality.
Everything is adapted to an existing stagnant cognitive system that falls far off the map of the scientific approach to information and evidence based medicine.  Perceiving only confirmations the physician health paradigm embodies and expresses preconceived ideas, values and mentalities based on certitude and absolute truth.

If one looks behind the curtain there is not much there.   Screen Shot 2015-06-16 at 3.39.59 AM

Historical, political, economic and social analysis can all show how the construct that exists today came to be.   This can be factually ascertained by simple reasoning and examination of the documentary evidence.

Any one of these analyses would reveal that the “PHP-blueprint” is a false-construct built on circumnavigation and obfuscation.

An evidence-based scrutiny of the literature would reveal it to be invalid and of little probative value.  A public policy analysis would reveal the logical fallacies involved in trumpeting  their positions including exaggerated rhetoric and  fear monitoring strategies designed to inspire moral panics and exploit fears to further an underlying political agenda

Any critical analysis would reveal cherry picking. proof by anecdote, deceptive propaganda, double talk, contradictory, illogical and incomprehensible jabber,  unprovable and  un-disprovable statements and a panoply of logical fallacy.

These groups  misrepresent, censor and suppress. They  nit pick and split hairs.  Screen Shot 2015-06-16 at 3.40.37 AMThe concept of denial is not just used to force people into treatment and justify abuse during treatment but  to suppress specific questions and deliberately avoid key facts.

So why are we not questioning this “authority?”     They have been left alone and basically thrown in the backyard left to proliferate like feral cats.

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We need anti-authoritarians and we need them now.

I need allies before the door closes for good. And that door may be closing a lot sooner than you think!

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“Addiction Medicine” is not recognized by the American Board of Medical Specialties (ABMS)–It is a “self-designated-practice specialty” (SDPS) and indicates neither knowledge nor expertise.

V0011377 A quack doctor selling remedies from his caravan; satirizingEducational and Professional Standards in Medical Specialties and Subspecialties

The increasingly rapid growth and complexity of medical knowledge in twentieth century American medicine resulted in the creation of specialties and subspecialties.

A related development was the creation of “boards”  to “certify” physicians as  knowledgeable and competent in the specialties and subspecialties in which they claimed to have expertise.   The American Board of Ophthalmology, organized in 1917, was the first of these.

As the number of medical specialties proliferated an umbrella organization was formed to accomplish this task. The Advisory Board for Medical Specialties was created  in 1933 and reorganized as the American Board of Medical Specialties (ABMS) in 1970.  This non-profit organization oversees board certification of all physician specialists and sub-specialists in the United States.

The ABMS recognizes 24 medical specialties in which physicians can pursue additional training and education to pursue Board Certification.Screen Shot 2014-11-07 at 7.44.56 PM

In 1991 the American Board of Medical Genetics was approved as the 24th ABMS board and these 24 boards grant the  37 general certificates and 88 subspecialty certificates available to medical specialists today.

The ABMS Member Boards are responsible for developing and implementing the educational and professional standards for quality practice in a particular medical specialty or subspecialty and evaluate physician candidates for Board Certification.  They set the bar of knowledge and competence for their given area of expertise.

All of the ABMS Member Boards are:

“committed to the principle of examining doctors based on six general competencies designed to encompass quality care: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.”

These areas have been collectively identified by the ABMS, the American College of Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) in order to standardize graduate medical education in any specialty  from medical school graduation through retirement.1

One of the  24 medical specialties ABMS recognizes in which physicians can pursue additional training and education and pursue Board Certification is Psychiatry.

Founded in 1934, The American Board of Psychiatry and Neurology (ABPN) is one of the 24 ABMS specialty boards. In 1959, the ABPN issued its first subspecialty certificate in Child and Adolescent Psychiatry and was the only ABNP subspecialty until 1991 when the first examination in Geriatric Psychiatry was administered.4 Addiction Psychiatry became a subspecialty of ABPN in 1993.

The ABPN governs the specialty of Psychiatry, of which Addiction Psychiatry is a subspecialty.   Board Certification in Addiction Psychiatry requires a four-year psychiatric-residency program for training in the prevention, diagnosis and treatment of mood, anxiety, substance-abuse as well as other psychological and interpersonal problems followed by an additional year of training in one of the 40 accredited Addiction Psychiatry Fellowship programs. The Accreditation Council for Graduate Medical Education (ACGME) is the professional organization responsible for the accreditation residency education programs in the US for ABMS specialty and subspecialty areas of medicine. Addiction Psychiatry training programs are governed by the ACGME and graduates are eligible for ABPN Certification in Addiction Psychiatry.

When this rigorous education and training is complete a candidate is Board Eligible and can then take the subspecialty certification exam. The exam assesses competency in the dand consultation, pharmacotherapy, pharmacology of drugs, psychosocial treatment and behavioral basis of practice to be Board Certified in the subspecialty of Addiction Psychiatry by the ABPN.

Candidates must then be assessed in  a number of areas including psychiatric evaluation and consultation, pharmacotherapy, pharmacology, toxicology, psychosocial treatment, behavioral basis of practice, and many other areas in which for the past half-decade they where taught and apprenticed.

The current structure of residency training is little changed from when it was conceived originally by William Stewart Halsted in the late 19th Century.  Physicians acquire knowledge and skills necessary to safely and competently manage patients through apprenticeship. Training in a specialty area provides a comprehensive platform that allows medical school graduates to apply a body of knowledge to patient care and the treatment of disease. This forms the foundation of our Guild–undifferentiated and general but pluripotential.

The American Academy of Addiction Psychiatry (AAAP) is the only professional organization in the US focused on the subspecialty of Addiction Psychiatry.   The AAAP Mission Statements are to: 2

  • PROMOTE HIGH QUALITY EVIDENCE-BASED SCREENING, ASSESSMENT AND TREATMENT FOR SUBSTANCE USE AND CO-OCCURRING MENTAL DISORDERS.
  • TRANSLATE AND DISSEMINATE EVIDENCE-BASED RESEARCH TO CLINICAL PRACTICE AND PUBLIC POLICY.
  • STRENGTHEN ADDICTION PSYCHIATRY SPECIALTY TRAINING AND FOSTER CAREERS IN ADDICTION PSYCHIATRY.
  • PROVIDE EVIDENCE-BASED ADDICTION EDUCATION TO HEALTH CARE TRAINEES AND HEALTH PROFESSIONALS TO ENHANCE PATIENT CARE AND PROMOTE RECOVERY.
  • EDUCATE THE PUBLIC AND INFLUENCE PUBLIC POLICY FOR THE SAFE AND HUMANE TREATMENT OF THOSE WITH SUBSTANCE USE DISORDERS.
  • PROMOTE PREVENTION AND ENHANCE ADDICTION TREATMENT AND RECOVERY ACROSS THE LIFE SPAN.
  • PROMOTE RESEARCH ON THE ETIOLOGY, PREVENTION, IDENTIFICATION AND TREATMENT OF SUBSTANCE USE AND RELATED DISORDERS.

Self-Designated Practice Specialty :  An AMA Census Term Indicating What a Group of Doctors are Calling Themselves.

Screen Shot 2014-03-18 at 5.22.16 PMThe American Medical Association records a physician’s Self-Designated Practice Specialty (SDPS) in response to an annual credentialing survey. According to the AMA, SDPS are “historically related to the record-keeping needs of the American Medical Association and do not imply ‘recognition’ or ‘endorsement’ of any field of medical practice by the Association. SDPS refers to a self-designated specialty and this is not equivalent nor does it imply ABMS [American Board of Medical Specialties] Board Certification.a_meissen_group_of_harlequin_and_the_quack_doctor_circa_1741_faint_blu_d5585085_001h

“The fact that a physician chooses to designate a given specialty/area of practice on our records does not necessarily mean that the physician has been trained or has special competence to practice the SDPS.”3

Physicians have been able to list addiction medicine as a self-designated area of practice using the specialty code “ADM” since 1990.Screen Shot 2014-11-07 at 7.45.43 PM

In contrast to these accepted board credentials, American Board of Addiction Medicine (ABAM)  certification requires only a medical degree, a valid license to practice medicine, completion of a residency training in ANY specialty, and one year‘s full time involvement plus 50 additional hours of medical education in the field of alcoholism and other drug dependencies. The majority of American Society of Addiction Medicine (ASAM) physicians meet these requirements by “working in a chemical dependency treatment facility, taking continuing medical education courses in addiction, or participating in research.”6

The American Society of Addiction Medicine’s mission is to “establishScreen Shot 2014-11-07 at 7.47.55 PM addiction medicine as a specialty recognized by professional organizations, governments,, physicians, purchasers, and consumers of health care products, and the general public.’5   They have succeeded in doing this as many consider them to be the experts in addiction medicine including regulatory agencies.

The goal of the American Board of Addiction Medicine (ABAM) Foundation is to “gain recognition of Addiction Medicine as a medical specialty by the American Board of Medical Specialties (ABMS).”

But Addiction Medicine is currently not recognized by the ABMS.  It is still a a Self-Designated Practice Specialty and the ABAM is a Self-Designated Board.  So too is the American Academy of Ringside Medicine and Surgery, the American Academy of Bloodless Medicine and Surgery and the Council of Non-Board Certified Physicians.   But these Self-Designated Boards do not have the multi-billion dollar drug and alcohol testing and treatment industry supporting them. Addiction Medicine has deep pockets, and if the November 2014 issue of the Journal of the American Medical Association (JAMA) is a harbinger of what’s to come, this self-designated practice specialty currently being certified by a self-designated Board and bereft of anything resembling the the educational and professional standards for quality practice in a particular medical specialty or subspecialty may soon robber baron its way into acceptance by the American Board of Medical Specialties.

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One thing is for certain.  When society gives power of diagnosis and treatment to individuals within a group schooled in just one uncompromising model of addiction with the majority attributing their very own sobriety to that model, they will exercise that power to diagnose and treat anyone and everyone according to that model.  The birth of Addiction Medicine as an ABMS accepted discipline is sure to be a success for the drug and alcohol testing and 12-step treatment industry, but its spawn is sure to be an inauspicious mark on the Profession and Guild of Medicine and a bane of society for years to come.

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  1. Stevens RA. In: Stevens R, Rosenberg C, Burns L, eds. History and Health Policy in the United States: Putting the Past Back in: Rutgers University Press; 2006:49-83.
  2. American Association of Addiction Psychiatry Website http://www.aaap.org/about-aaap/mission-statement (accessed 4/2/2014).
  3. American Medical Association. List & Definitions of Self-Designated Practice Specialties. August 21, 2012 http://www.ama-assn.org/ama.
  4. Juul D, Scheiber SC, Kramer TA. Subspecialty certification by the American Board of Psychiatry and Neurology. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. Spring 2004;28(1):12-17.
  5. http://www.asam.org/about-us/mission-and-goals.
  6. Tontchev GV, Housel TR, Callahan JF, Kunz KB, Miller MM, Blondell RD. Specialized training on addictions for physicians in the United States. Substance abuse : official publication of the Association for Medical Education and Research in Substance Abuse. Apr 2011;32(2):84-92.
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“mail order” expertise; Diploma Mill

Drug Companies and Doctors: A Story of Corruption

Drug Companies and Doctors: A Story of Corruption.

What we need is a Marcia Angell to take on the multi-billion dollar drug and alcohol testing, assessment and treatment industry.

Screen Shot 2015-06-01 at 7.22.25 PMWhile all eyes were focused on the drug companies these multi-billion dollar industries erected a scaffold of immunity and profit by removing (and blocking) themselves from essentially all aspects of accountability; answerability, justification for actions and the ability to be punished by outside actors.    The 2009 quote in reference to “big pharma”  is just as applicable to the drug and alcohol testing industry,”  the inpatient assessment and treatment centers and the “authorities” pushing public policy and swaying public opinion to accept irrational and illegitimate authoritative opinion as truth.

And unlike the pharmaceutical industries carefully constructed “bent science” which requires a keen eye and critical analysis , the evidence-base supporting the testing, assessment and treatment industry rests on a foundation that can be aptly characterized as illusions and lies.  The “science” is not just “junk-science” but junk-science of the lowest order–examples of confirmatory distortion and data-dredging to make the data fit the hypothesis abound.   The conflicts-of-interest are not potential but incestual with many of the key players putting their hands in every slice of the pie!

The bad science, bad medicine, bad policy and  bad actors are easy to identify. It would be like shooting fish in a barrel.

So what are the barriers?

Why has this not been done?

The answer to that is complex but  involves a confluence of factors including psychological, political and cultural.  “Feel good fallacy,”  “political correctness, and moral and policy entrepreneurship have effectively swayed the targets intended.  The well-funded misinformation and propaganda was cast with a large net using the same techniques others have successfully used throughout history to accomplish the same.  Moral panics, moral crusades, and a plethora of logical fallacy have been used and used with considerable resources and skill.

So what can we do about it?

The first “step into the breach” is to identify the problem with the first one being the Emperor has no clothes.  Once this is acknowledged it would not take long to address directly the specific problems and erroneous assumptions of this paradigm through the lenses of science, critical reasoning, ethics and common sense.  If this were to be done the entire Potemkin village would fall like a house of cards.

But the very first and simplest step is to use your voice to question this authority. Make it be known.

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History teaches us that silence and secrecy are often the most effective tools of power.   It hides things including very bad things.  It is time to shine a light on this dank dark corner of the medical profession.


It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine” – Marcia Angell 

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“At times to be silent is to lie. You will win because you have enough brute force. But you will not convince. For to convince you need to persuade. And in order to persuade you would need what you lack: Reason and Right”
― Miguel de Unamuno

“I have always found it odd that people who think passive aggressively ignoring a person is making a point to them. The only point it makes to anyone is your inability to articulate your point of view because deep down you know you can’t win. It’s better to assert yourself and tell the person you are moving on without them and why, rather than leave a lasting impression of cowardness on your part in a person’s mind by avoiding them.”
― Shannon L. Alder

Staying silent is like a slow growing cancer to the soul and a trait of a true coward. There is nothing intelligent about not standing up for yourself. You may not win every battle. However, everyone will at least know what you stood for—YOU.”
― Shannon L. Alder


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Disrupted Physician 101.2: “Addiction Medicine” is a Self-Designated Practice Specialty Unrecognized by the American Board of Medical Specialties–(An AMA Census Term Indicating Neither Training nor Competence)

“Spirituality can go hand-in-hand with ruthless single-mindedness when the individual is convinced his cause is just”

Michela Wrong, In the Footsteps of Mr. Kurtz: Living on the Brink of Disaster in Mobutu’s Congo

Addiction Medicine: The Birth of a New Discipline

Addiction Medicine is currently not recognized by the American Board of Medical Specialties (ABMS).  It is still a a Self-Designated Practice Specialty and the American Board of Addiction Medicine is a Self-Designated Board.  So too is the American Academy of Ringside Medicine and Surgery, the American Academy of Bloodless Medicine and Surgery and the Council of Non-Board Certified Physicians.  But these Self-Designated Boards do not have the multi-billion dollar drug and alcohol testing and treatment industry supporting them. Addiction Medicine has deep pockets, and if the November 2014 issue of the Journal of the American Medical Association (JAMA) is a harbinger of what’s to come, this self-designated practice specialty currently being certified by a self-designated Board and bereft of anything resembling the educational and professional standards for quality practice in a particular medical specialty or subspecialty as defined by the ABMS, the American Council on Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) may soon robber baron its way into acceptance by the Medical Profession.

One thing is for certain.  When society gives power of diagnosis and treatment to individuals within a group schooled in just one uncompromising model of addiction with the majority attributing their very own sobriety to that model, they will exercise that power to diagnose and treat anyone and everyone according to that model.  The birth of Addiction Medicine as an ABMS accepted discipline is sure to be a success for the drug and alcohol testing and 12-step treatment industry, but its spawn is sure to be an inauspicious mark on the Profession and Guild of Medicine and a bane of society for years to come.

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via Disrupted Physician 101.2: “Addiction Medicine” is a Self-Designated Practice Specialty Unrecognized by the American Board of Medical Specialties–(An AMA Census Term Indicating Neither Training nor Competence).

 

Disrupted Physician 101.3 –“For What it’s Worth”— The ASAM/ABAM Diploma Mill

“In a time of universal deceit, telling the truth is a revolutionary act.”
— George Orwell

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I can think of no other specialty or subspecialty in the profession of medicine where non-existent expertise can be incontestably announced and implemented.  If I claimed to be an ace neurosurgeon or an expert otolaryngologist and started practicing my claimed skills in the hospital I would be called on it pretty quick by both colleagues and patients–deemed a delusional fraud and run out on a rail within a week.  Both law enforcement, attorneys and psychiatry would be called in short order.

Yet doctors who have not met the usual and customary standards for professional and educational quality that have been identified for medical specialties and subspecialties are able to claim expertise in “addiction medicine” and everybody just lets them.

To make this point I sat for the 2010 American Board of Addiction Medicine Certification Examination.  I did this to make a point–kind of like seeing how easy it is to buy a gun at a Walmart.

I simply went to the ABAM Website, completed the application and paid the fee.

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The requirements to sit for the exam included so many “practice experience hours” over the past five years and 50 CME credits related to addiction.

With a year of psychopharmacology research, a half-day per week moonlighting at the MBTA medical clinic giving drug tests to bus drivers and another overnight moonlighting job giving medical clearance to patients at a local psychiatric hospital detox unit I satisfied the first requirement.   For the latter I looked through the last five years of morning reports, noontime lectures and grand rounds I went to and added them up and, falling a little short supplemented the CME credits with some online modules.

And with that I was given a date at Pearson to take the test.

I have absolutely no training or education in the field of addiction medicine.  I didn’t pick up a book or study anything. I did not prepare at all. I did not even get a good night’s sleep the night before and stayed up until 2:30 a.m.   Nevertheless I went to the testing facility the next morning and finished the test within an hour and a half.  My score is below.  Aced it.   Passing score was 394 and I got a 459.

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And the point I am trying to make is I am no expert in Addiction Medicine.  Neither is 4000 of me. Yet the letter below says I am.  Majority apparently rules.

Giving false expertise to the unqualified and granting them power over others is just as dangerous as the gun from Walmart.  They can both kill.

An interest in something does not an expert make. If we allow this then the ASAM 12-step chronic brain disease model not only swallows addiction medicine but tarnishes all of medicine.  An imposition by force and the deep pockets of the billion dollar drug and alcohol testing, assessment and treatment industry.

ASAM is not a true medical specialty. It is a special interest group.   ABAM is not recognized by the American Board of Medical Specialties (ABMS).

The arguments seem to be:

1) Addiction is a prevalent “disease”  that needs to be “treated;”

2) There are not enough Addiction Psychiatrists to diagnose and treat them.

3) Being an M.D. addict or alcoholic gives enough knowledge and apprenticeship skills to diagnose and treat others with the same affliction.

4) Let’s utilize them to fill the void.

This is logical fallacy and it is dangerous.

The validity and reliability of opinions lie in their underlying methodology and evidence base. Reliance on the personal authority of any expert or group of experts is the fallacy of appeal to authority.

An interest in something does not an expert make.  I had an interest in science as a child but my certification as a member of Sir Isaac Newton’s Scientific Club did not make me a scientist.

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I have asthma but that does not make me a Pulmonologist.  That addiction “specialist” diagnosing and treating you may have 5 years prior been a proctologist; and maybe not even a very good one at that.

Somewhere there may be doctor with no post-graduate training in surgery wielding a scalpel and calling himself an expert surgeon, but it is difficult to imagine that he is a very good one.

I received my ABMS certification without meeting a single person. It was all done by mail.   This fits the very definition of “Diploma Mill.”  This is not to besmirch those with a sincere interest in helping others with addiction.  Many if not most of those involved are sincere. But this is not expertise.  This is not authority. And, as we have seen, this low bar opens the door for some very bad apples.

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“This election is not about issues,” Rick Davis, John McCain’s campaign manager said this week. “This election is about a composite view of what people take away from these candidates.” That’s a scary thought. For the takeaway is so often base, a reflection more of people’s fears and insecurities than of our hopes and dreams.
— Judith Warner, New York Times, September 4, 2008

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